1. Chapter 79:
Endocrine Disorders

2. The Endocrine System Endocrine system
Regulates nearly all body processes
Endocrine glands
Groups of cells that produce chemical substances called hormones
Endocrine disorders
Caused by overproduction or underproduction of specific hormones

3. Diagnostic Tests Tests for diabetes mellitus Blood tests
Fasting plasma glucose
FPG greater to or equal to 126 mg/dl obtained on two or more occasions confirms a Dx of DM

4. Diagnostic test Oral glucose tolerance test Glycosylated hemoglobin
Measurement that reflects the clients average blood glucose level over the previous 2-3 months.
Range should be 5-7%
Estimated average glucose
Glycemic index
Measurement of how foods containing CHO’s raise blood sugar
Urine tests
Keto-Diastix test

5. Pancreatic Endocrine Disorders
Diabetes mellitus
Type 1 insulin-dependent diabetes mellitus (IDDM); or juvenile diabetes
Type 2 non–insulin-dependent diabetes mellitus (NIDDM); or adult-onset diabetes
Gestational diabetes mellitus (GDM)

6. Pancreatic Disorders Prediabetes Impaired glucose homeostasis (IGH)
Blood glucose levels are high but not high enough for the definitive diagnosis of DM
AKA:
impaired fasting glucose (IFG)
impaired glucose tolerance (IGT)

7. Type 1 and Type 2 Diabetes Mellitus
Age of onset
Under 30 years
Over 30 years
Classic symptoms
Nearly always present
Usually not present
Hereditary factors
Occasionally present
Usually present
Weight
Normal or underweight
Usually overweight
Ketoacidosis
Susceptible
Not susceptible
Usual treatment
Insulin, meal plan, exercise
Meal plan, exercise, oral medications, or insulin

8. Signs and Symptoms
3 “p”s : polyuria, polydipsia, polyphagia (found more often in type I and come on rapidly)
Metabolic syndrome is a combination of at least three conditions commonly found in prediabetics: obesity, HTN, high blood glucose, insulin resistance and or dyslipidemia

9. Type 1 DM DO NOT MAKE INSULIN-tx for life!!
Results from destruction of the pancreatic beta cells because these cells have been damaged or destroyed by an autoimmune process

10. Type 2 DM Etiology is not understood
Revision of lifestyle and weight loss are very beneficial to prediabetic and type 2 diabetic individuals
Risk factors include being overweight, age, lack of exercise
New onset Type 2 DM requires teaching and lifestyle changes!!
Consult diabetes nurse educator

11. Antidiabetic Agents Box 79-1
sulfonylureas-increase insulin production in the pancreas and promote the effectiveness of available insulin
1st generation
2nd generation
Glyburide-if a patient takes this drug and vomits an hour later they should be monitored for hypoglycemia*
Glipizide
glimepiride
Meglitinides
Alpha-glucosidase inhibitors
acarbose
thiazolidinediones

12. Treatment
Diet
Presence of complications such as infection (INCREASES BS), decreased cardiovascular stamina, or neuropathies
Measurement of the CHO levels or GI (“white”high index)
Exercise plan
Monitor blood glucose before and after exercise
Ingest added CHO’s if glucose is under 100 mg/dl and maintain adequate hydration
Making appropriate insulin adjustments based on blood glucose readings is essential
Medication

13. Insulin Goal of insulin therapy
To mimic the body’s natural levels of insulin
Most often use sliding scale
All liquid insulins can be given subcutaneously, but only regular insulin can be given both subcutaneously and IV
Use, care, and storage
Administration angle 45 and 90 degrees subcutaneously
Vials or prefilled syringes should be crystal clear or milky white
discard if discolored or do not re-suspend when you roll them, if there is a frosting or coating on the bottle

14. Some Types of insulins Insulin Onset Peak Duraction characteristics
Regular short acting:
lispro
aspart
glulisine
15-30* min h
3-5 hours
Clear
Give just before a meal*
Intermediate:
isophane-NPH
Humulin N
1-4 hours
4-12 hours *
Average 6-10*
10-16 hours
cloudy
Long acting:
glargine
detemir
1-2
None 24
Do not mix with other insulins

15. Other Medications Pramlintide (Symlin)
Synthetic drug based on the hormone amylin injected at meal times to improve average blood glucose levels (HA1C or eAG).
It cannot be combined with insulin.
Insulin coverage
Insulin pumps-inject medication automatically
Oral diabetes medications-several categories
Pancreas transplantation

16. Complications of Diabetes Mellitus
Hypoglycemic reaction-BG <70 mg/dl
S/S:
Pale, moist, clammy, sweating, shaky, irritable, dizziness, seizures
Treatment
CHO, if conscious give sugar in some form
Unconscious-give them glucagon IM or D50 IV

17. Complications of DM Hyperglycemia
DKA-TYPE 1 DM only; to many ketones accumulate and body fluids become imbalanced
S/S:
Headache, malaise, vision changes, dehydration, sweet odor to breath, breathing and pulse are rapid and deep and the blood pressure is low
Treatment
Continuous infusion of low dose regular insulin with a controlled flow mechanism is used

18. Nonketotic hyperosmolar state
BG level of 1000 mg/dl
Occurs most often in older adults with no Hx of DM or Hx of Type 2 DM
S/S
Hyperglycemia, severe dehydration and coma
Treatment
Continuous low dose infusion of insulin and aggressive fluid replacement

19. Infections Infections Aggravate DM
Susceptible to yeast and fungal infections
Carbuncles and furuncles
Common colds and flu
Surgical complications
Surgical risks
Difficulty in regulating insulin postop

20. Macrovascular complications
Arteriosclerosis
HTN
PVD MI
CAD
CVA
Slow healing time

21. Microvascular complications
Nephropathy
Kidney disease can result in kidney death
Neuropathy
Peripheral neuropathy usually starts as numbness or tingling in the toes and progresses gradually
Painful neuropathy can be treated with gabapentin, amitriptyline, carbamazepine*
Retinopathy
Leading cause of blindness

22. Long-Term Management of Diabetes Mellitus
Client teaching
The person feels well (DM is managed)
Healthcare provider contact
For insulin adjustment
Glucose monitoring
Using blood glucose monitor at home

23. Long-Term Management of Diabetes Mellitus
Meal planning
Individualized
Must understand the relationship among diet, medication and exercise
Lifestyle factors
Avoid fatigue
Smoking
Contraindicated d/t vasoconstrictor effect of nicotine
Insulin injection
Teach about the type of insulin, rotating sites (insulin most rapidly absorbed from the abdomen)
Alternative forms of insulin administration (pump)

24. Long-Term Management of Diabetes Mellitus
Hypoglycemia and hyperglycemia
Frequent monitoring of blood glucose levels
Carry simple CHO snack
Glucagon/glucose emergency kit is recommended for clients receiving insulin; family members should know how to use it**
Sexuality
May experience ED
Exposure to cold
Decreases blood circulation in extremities d/t vasoconstriction

25. Long-Term Management of Diabetes Mellitus
Vision impairment
Importance of annual eye exams
Dental examination
Dental caries may lead to infections which can imbalance glucose control

26. Long-Term Management of Diabetes Mellitus
Foot care
Poor circulation and diminished sensation can result in a wound that is not detected by the client and does not heal
In practice 79-2
Inspect feet daily
Cut nails straight across with a blunt tipped scissors
Do not walk barefoot
Put lambs wool between overlapping toes
Never wear constrictive stockings or socks
Nonelastic!

27. Long-Term Management of Diabetes Mellitus
Traveling
May need to adjust insulin during travel
Identification
Should wear a medic alert tag